Flatbed Express Inc.

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Driver's Application for Qualification
Position's Applied for: Local/Daily Regional O.T.R.

First Name

Middle Name

Last Name

Social Security #

List your addresses of residency for the past 3 years:

Current Address	Street	City	State	Zip	() - Phone
	How long have you occupied the residence?				() - Cell Phone
Previous Addresses	Street	City	State	Zip	How Long?
	Street	City	State	Zip	How Long?
	Street	City	State	Zip	How Long?

Date of Birth:	/ / Month / Day / Year	Do you have the legal right to work in the United States?	Yes No
		If no, please explain:

Have you worked for this company before?	Yes No		Dates: From to
If yes above, reason for leaving:

How did you hear about us? Newspaper: Referred by:

Is there any reason you might be unable to perform the essential functions of the job for which you have applied? Yes No
Essential Functions: There may be duties in addition to the driving task for which a driver is responsible and needs to be fit. Some of these responsibilities are: coupling and uncoupling trailer(s), lifting, installing, and removing heavy chains, binders, and occasionally tarps. These tasks demand the ability to bend and stoop, the ability to maintain a crouching position to inspect the underside of the vehicle, frequent entering and exiting of the cab, and the ability to climb ladders on the tractor and/or trailer(s).

If yes, explain:

EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employment (including non-driving jobs) during the preceding 3 years. List complete mailing address, street number, city, state, zip, phone #, and dates employed.
Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.

Note: List all employers in reverse order starting with the most recent.

Employer 1
Name	From	To
Address	Position Held
City State Zip	Contact Person
Reason for Leaving	Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 2
Name	From	To
Address	Position Held
City State Zip	Contact Person
Reason for Leaving	Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 3
Name	From	To
Address	Position Held
City State &nbs; Zip	Contact Person
Reason for Leaving	Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 4
Name	From	To
Address	Position Held
City State &nbs; Zip	Contact Person
Reason for Leaving	Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 5
Name	From	To
Address	Position Held
City State &nbs; Zip	Contact Person
Reason for Leaving	Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 6
Name	From	To
Address	Position Held
City State &nbs; Zip	Contact Person
Reason for Leaving	Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 7
Name	From	To
Address	Position Held
City State &nbs; Zip	Contact Person
Reason for Leaving	Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 8
Name	From	To
Address	Position Held
City State &nbs; Zip	Contact Person
Reason for Leaving	Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 9
Name	From	To
Address	Position Held
City State &nbs; Zip	Contact Person
Reason for Leaving	Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 10
Name	From	To
Address	Position Held
City State &nbs; Zip	Contact Person
Reason for Leaving	Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 11
Name	From	To
Address	Position Held
City State &nbs; Zip	Contact Person
Reason for Leaving	Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed to use to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Accident Record for the past 3 years or more.
Have you had you any accidents for the past 3 years or more? Yes No

Dates	Nature of Accident (Backing, Rear End, Rollover, Turning, etc)	Location	Amount	Fatalities	Injuries
Last Accident:
Next Previous:
Next Previous:
Next Previous:
Next Previous:

Traffic Convictions and forfeitures for the past 3 years (other than parking violations).
Have you had you any traffic convictions and forfeitures in the past 3 years (other than parking violations)? Yes No

Date	Location	Charge	Penalty

Experience and Qualifications
List all driver licenses or permits held in the past 3 years.

DRIVER LICENSES	State	License No	Type	Endorsements	Expiration Date

A) Have you ever been denied a license, permit, or priviledge to operate a motor vehicle?	Yes No
B) Has any license, permit, or privledge ever been suspended or revoked?	Yes No
C) Have you ever been convicted of a DUI or DWI?	Yes No
D) Have you ever been convicted of a felony or misdemeanor?	Yes No
If yes to any of the above questions, give details:

Driving Experience

Class of Equipment	Type of Equipment (Van, Reefer, Hopper, Tanker, Flat, Etc.)	Dates		Approx Number of Miles
Straight Truck		From	To
Tractor & Semi-Trailer		From	To
Tractor - 2 Trailers		From	To
Motorcoach / Bus	-	From	To
Other		From	To

Class A License originall issued when?

Total number of years of Tractor / Trailer experience:

Select all areas that you have driven in:

Local West Midwest South East Mountains 48 States
Canada Mexico

- OR- List states operated in for last 5 years:

Special cources or training that will help you as a driver:

Which safe driving awards do you hold and from whom?

Please select Highest Grade Completed (Grade School):
1 2 3 4 5 6 7 8 9 10 11 12

College:
1 2 3 4 5

Post-Graduate:
1 2 3 4

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the previous Sections 604(b)(2)(A) of the Fair Credit Reporting Act, (Public Law 91-508), as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying your previous employment, driving record and previous drug and alcohol test results may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.25 and 391.25 of the Federal Motor Carrier Safety Regulations.

INVESTIGATIVE CONSUMER REPORT DISCLOSURE

In connection with your employment or application for employment (including contract for services), an investigative consumer report and consumer reports, which may contain public record information, may be requested from DAC / USIS Commercial Services. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, drug/alcohol use, information relating to your character, general reputation, personal characteristics, mode of living, educational background, or any other information about you which may reflect upon your potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. Such reports may contain public record information concerning your driving record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state, and other agencies which maintain such records; as well as information from DAC / USIS concerning previous driving record requests made by others from such state agencies.

You have the right to receive, upon your written request within reasonable period of time, (not to exceed 30 days) a complete and accurate disclosure of the nature and scope of the investigation requested. You have the right to make a request to DAC / USIS, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information, and the recipients of any reports on you that DAC / USIS has previously furnished within the two-year period preceding your request. DAC / USIS may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74153, or by phone at (800) 381-0645.

A written summary of your rights under the Fair Credit Reporting Act (FCRA) as prepared by the Federal Trade Commission is available upon request. You also have the right to review the information obtained from previous employers, to correct errors in that information and rebut perceived incorrect information. Such requests must be made in writing prior to accepting employment with the Company.

TO BE READ AND SIGNED BY APPLICANT

I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

I authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other such persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

Review Information provided by previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment files.
It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me.
It is agreed and understood that if qualified to operate motor carrier equipment, I may be on a probationary period, during which I may be disqualified without recourse.

Applicant's Electronic Signature:

I UNDERSTAND CHECKING THIS BOX THIS CERTIFIES THAT THIS APPLICATION WAS COMPLETED BY ME, AND THAT ALL ENTRIES ON IT AND INFORMATION IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

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